Innovations

Post-discharge adverse drug events (ADEs) are one of the most common preventable harms leading to hospital readmission in the United States.^1,2 To improve medication-related safety and reduce hospital readmissions, the Memphis Veterans Affairs Medical Center (VAMC) started a transitional care clinic (TCC) led by clinical pharmacy specialists (CPSs) who provide follow-up care to patients after they are discharged from the hospital or emergency department (ED). CPSs are independent mi

In the early days of the COVID-19 pandemic, New York Presbyterian Weill Cornell Medical Center and Lower Manhattan Hospital faced multiple challenges.

Studies show that home visits to patients recently discharged from the hospital can help prevent unnecessary readmission.¹ Providing continuing care instructions to patients in their homes—where they may be less overwhelmed than in the hospital—may also be a key mechanism for preventing readmission.² Home visit clinicians and technicians can note any health concerns in the home environment and help patients understand their care plan in the context of that environment.²

Venous thromboembolism (VTE) is a serious but preventable medical condition in which blood clots form in the veins.

An increasing volume of patients presenting for acute care can create a need for more ICU beds and intensivists and lead to longer wait times and boarding of critically ill patients in the emergency department (ED).¹ Data suggest that boarding of critically ill patients for more than 6 hours in the emergency department leads to poorer outcomes and increased mortality.^2,3 To address this issue, University of Michigan Health, part of Michigan Medicine, developed an ED-based ICU, the first of its kind, in its 1,000-bed adult hospital.

Mobile health apps are becoming increasingly popular for patients and clinicians. This innovative study implemented a pharmacist-led mobile health based intervention to improve medication safety of patients following kidney transplant.

Checklists are used in many clinical settings to improve patient safety. This pediatric intensive care unit updated a static checklist, eSIMPLE, to a dynamic, decision-support enhanced checklist, eSIMPLER. 

Obtaining a best possible medication history is the cornerstone of medication reconciliation but can be resource-intensive. This comparison study assessed the impact of virtual pharmacy technicians (vCPhT) obtaining best possible medication histories from patients admitted to the hospital from the emergency department. 

A lack of situational awareness can lead to delayed recognition of patient deterioration. This children’s hospital developed and implemented a situational awareness framework designed to decrease emergency transfers to the intensive care unit (ICU).

With the PICC Use Initiative, the Michigan HMS, which currently includes 62 non-governmental hospitals in Michigan, aims to improve the safety of hospitalized patients by eliminating unnecessary PICC use and preventing PICC-associated complications. Since infectious diseases (ID) physician approval for PICC use is one promising strategy to reduce inappropriate use, the consortium helped promote and facilitate data collection for this patient safety strategy.

The Revised Safer Dx Instrument provides a standardized list of questions to help users retrospectively identify and assess the likelihood of a missed diagnosis in a healthcare episode. Results of the assessment are intended for use in system-level safety improvement efforts, clinician feedback, and patient safety research.

The Veterans Health Administration (VHA) Stratification Tool for Opioid Risk Mitigation (STORM) decision support system and targeted prevention program were designed to help mitigate risk factors for overdose and suicide among veterans who are prescribed opioids and/or with opioid use disorder (OUD) and are served by the VHA.¹ Veterans, particularly those prescribed opioids, experience overdose and suicide events at roughly twice

Understanding the ways in which human factors, such as non-technical skills, influence individual and team performance can ultimately improve patient safety, particularly in high-intensity settings such as operating rooms.

The relationship between burnout among healthcare workers and poor patient safety outcomes has been well-documented

The handshake antimicrobial stewardship program (HS-ASP) was developed and implemented at Children’s Hospital Colorado (CHCO). In 2014, the CHOC HS-ASP team began labeling specific interventions as “Great Catches” which were considered to have altered, or had the potential to alter, the patient’s trajectory of care. CHOC researchers used these "Great Catches" to identify potential diagnostic errors.

Medication administration errors are a common source of patient harm.

ECHO-Care Transitions (ECHO-CT) intends to ensure continuity of care and alleviate the risk of patient safety issues, notably medication errors, occurring because of hospital transition. With funding from the Agency for Healthcare Research and Quality, Beth Israel Deaconess Medical Center (BIDMC) adapted Project Extension for Community Healthcare Outcomes (ECHO) to connect receiving multidisciplinary skilled nursing facility (SNF) teams with a multidisciplinary team at the discharging hospital.

The MOQI seeks to reduce avoidable hospitalization among nursing home residents by placing an advanced practice registered nurse (APRN) within the care team with the goal of early identification of resident decline. In addition to the APRN, the MOQI involves nursing home teams focused on use of tools to better detect acute changes in resident status, smoother transitions between hospitals and nursing homes, end-of-life care, and use of health information technology to facilitate communication with peers. As a result of the innovation, resident hospitalizations declined.

The Behavioral Health Vital Signs (BHVS) screener is a patient questionnaire input into the electronic health record for depressive symptoms, alcohol and substance use, and interpersonal violence. Widespread staff education and a standardized workflow were developed to ensure that BHVS was implemented in all primary care clinics within the San Francisco Health Network.